When and How to Report a Medical Malpractice Insurance Incident or Claim

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By Julie Danna

 

Many of my clients hesitate to report a potential incident or claim to their medical malpractice insurance carrier because they fear a cancellation notice or the loss of claims-free credits.

Have you had or do you know of an incident, claim, or potential claim that you did not report to your current insurer? Not every concern needs to be reported, but, what happens if an incident is not reported and it turns into a claim?  The fact that a provider “knew” of a situation and did not report it could potentially result in a denial of coverage, particularly when switching insurers. Therefore, I strongly encourage my clients to report any incident they reasonably believe may lead to a claim.

Most standard Florida med mal policies are called “claims made” coverage, and have an “incident-sensitive trigger,” so the carrier will defend incidents reported during the policy term that date back to your current retroactive date. Both an incident report and the filing of the claim must happen while the policy is in effect.

The difference between an incident and a claim:

An incident is an unfortunate or unanticipated event causing an injury or an event that created a potential for injury or damages.

Claims are classified into two basic categories: formal and informal. A formal claim is when you either receive a letter from a claimant or attorney or are served a legal document. A request for medical records by your patient or an attorney should be considered a formal claim unless the request is unrelated to the care you provided.

An informal claim typically is just a verbal threat, the most common being a threat of litigation or a request to waive fees or service billings.

Types of incidents that lead to claims and should be reported:

  • Deceased patient
  • Birth injuries
  • Reduced life expectancy
  • Severe disfigurement
  • Loss of an extremity
  • Injury to or impairment of any of the five senses
  • Verbal or written threats
  • Harassment by a patient’s family

Additional examples of what you should report to the claims department:

  • Demand for money
  • Verbal or written threat of legal action
  • Formal paper naming you as a defendant or witness
  • Attorney notice of intent to sue or a 90-day notice of intent
  • Request for arbitration
  • Request for a deposition or interview, or receipt of a subpoena, summons, or complaint

After a claim or incident has been reported:

  • Do not discuss the case with anyone except your claims manager or an attorney retained to represent you, protected peer-review attendees, or your spouse. Discussing the case increases the possibility of others being subpoenaed and/or conflicting information being circulated.
  • Never alter a medical record after a claim has been made. This includes making additions, corrections, or deletions.
  • Do not include any claims correspondence in the patient’s medical record.
  • Maintain copies of all claims correspondence in a secure location.

One final note of caution: We are seeing a number of doctors being asked by plaintiff attorneys to “help” with understanding the medicine involved in lawsuits filed against another doctor or doctors by patients for whom you might also have provided care. You might be told that such interviews are “just for background” and that you are not the target of the lawsuit(s); thus, you might let your guard down and not reach out to your insurer to request a lawyer to protect you in these often-tricky interviews that can lead to you being sued in the same case as well.

To learn more about reporting an incident or claim, please feel free to contact Julie Danna at julie@dannagracey.com or directly on her cell at 850.530.3924.